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ARCHI Quarterly Breakfast
March 15, 2017
Mike CarnathanManager of Research and AnalyticsAtlanta Regional Commission
Atlanta Transformation
Scenario
Encouraging Healthy Behaviors
Family Pathways
Coordinated Care
Global Payment
Capture and Reinvest
Expand Insurance
Innovation Fund
Health Reform UpdateARCHI BreakfastMarch 15, 2017
4
44%
2%
19%
0%
36%
I am currently most worried about…
A. MedicaidB. Disproportionate
Share Hospital (DSH) payment
C. Private insuranceD. Having enough coffeeE. Everything!
67%
0% 4% 4% 2%
22%
What are doing to keep up with health reform?
A. Watching, listening, reading the news
B. Reading the billsC. Signing up for listservsD. Following social mediaE. Wine, lots of wineF. All of the above
Yes No
42%
58%
Do you know the difference between a block grant and a per capita cap?
A. YesB. No
ACA Recap
• Market reforms• Pre‐existing condition protections• Individual and employer mandates• Health insurance exchanges• Premium subsidies
• Medicaid• Expansion for childless adults• DSH payment cuts
• Financing• Mandate penalties• New taxes: tanning beds, medical devices, health insurance, high income Medicare beneficiaries, etc.
ACA Passage Timeline
Prior Proposals
• Tom Price: Empowering Patients First• Paul Ryan: A Better Way• Pete Sessions: World’s Greatest Healthcare Plan• Bill Cassidy and Susan Collins: Patient Freedom Act• Rand Paul: Obamacare Replacement Act• Richard Burr, Orrin Hatch, and Fred Upton: Patient Choice, Affordability, Responsibility, and Empowerment (CARE) Act
Legislative Reality
• Senate requires 60 votes to end debate and bring a bill to a floor vote
• Republicans have 52 Senate seats• Can use reconciliation to avoid a filibuster:
• Can only make changes to money portions of a current bill or law
• Requires a simple majority for passage• Cannot be used to fully repeal the ACA
American Health Care Act
• Market Reforms• Repeals individual and employer mandates, but requires continuous coverage to avoid a 30% surcharge
• Replaces premium tax credits with a universal health care tax credit• Maintains protections for pre‐existing conditions• Expands use of Health Savings Accounts• 5:1 premium age ratio
• Medicaid • Sunsets Medicaid expansion in 2020• Per‐capita caps on federal spending• Restores pre‐ACA DSH payments
• State innovation grants• Financing: Repeals most of the ACA’s taxes
12
CBO Report
• Reduce deficit by $337 billion by 2026• 14 million additional uninsured in 2018• 24 million additional uninsured by 2026, largely due to changes in Medicaid financing and eligibility
• 52 million uninsured Americans in 2026 compared to 28 million under the ACA
• Higher premiums in next two years; by 2026 average premiums will be 10% lower than under current law
• Higher premiums for older adults; lower premiums for younger adults
• No change in market stability
ACA vs. AHCA
http://kff.org/interactive/tax‐credits‐under‐the‐affordable‐care‐act‐vs‐replacement‐proposal‐interactive‐map/
ACA vs. AHCA
• Fulton County resident making $30,000 / year• 27 years old: ACA: $680; AHCA: $2,000 (+193%)• 40 years old: ACA: $1,380; AHCA: $3,000 (+117%)• 60 years old: ACA: $5,710; AHCA: $4,000 (‐30%)
• Dougherty County resident making $30,000 / year• 27 years old: ACA: $3,510; AHCA: $2,000 (‐43%)• 40 years old: ACA: $4,830; AHCA: $3,000 (‐38%)• 60 years old: ACA: $13,040; AHCA: $4,000 (‐69%)
Reaction to the AHCA
• Support• President Trump, House Speaker Paul Ryan, House leadership
• Senate majority leader Mitch McConnell and Senate leadership
• Chamber of Commerce
• Oppose• AMA, ANA, AHA, AARP, AHIP (partly)• Republican governors in expansion states• Tea Party Republicans in Congress
Adaptive Actions
17
Influence decisions Educate others Strategically plan under uncertainty
Stay abreast of new information that emerges
Create new partnerships Build capacity: workforce, information technology, and care coordination
© Georgia Health Policy Center, Georgia State University, 2013
Table Exercise
Betterprepared
Optimistic Energized Uncertain
41%
4%9%
46%
How do you feel about health reform now?A. Better preparedB. OptimisticC. EnergizedD. Uncertain
16%
28%
16% 17%20%
3%
Which adaptive actions will you focus on?A. Influence decisionsB. Educate othersC. Strategically plan
under uncertaintyD. Stay abreast of new
informationE. Create new
partnershipsF. Build capacity
Creating a Clear Path for Atlanta’s Homeless
Cathryn Marchman, LCSW, Esq., Executive DirectorARCHI Quarterly Breakfast, March 15, 2017
What is a Continuum of Care?
Note: Georgia has 9 Continua of Care
A CoC is designed to promote communitywide commitment to the
goal of ending homelessness US Housing and Urban Development term of art
Atlanta’s CoCwas established in 2013 by Mayor Reed, authorized
by the City Council, and consists of 3
entities:
Governing Council
17 members
CoCMembership
70+ organizations including 17 HUD
funded
Partners for HOME, Inc.
Independent 501c Agency
24
Unprecedented federal strategic leadership, partnership and alignment2016 HUD funding priorities• Strategic Resource Allocation • Housing First Approach • Systemic Response to Homelessness: Coordinated Entry
and performance driven system• End Chronic Homelessness* • End Veteran Homelessness* • End Family Homelessness • End Youth Homelessness *HUD/USICH defined through predetermined benchmarks and criteria
Vision for creating a Clear Path for Atlanta’s homeless
System transformation
Housing FirstCoordinated entrySystem performance measures
Using Evidenced Based Best Practices
Data informed decision making Harm reductionTrauma informed careMotivational interviewing
Collective alignment
Unprecedented collaboration among public and private sectorRight sized housing interventions using PSH and RRH
Slide/material adapted from Houston’s, A Way Home
Slide from Houston’s, A Way Home
Current Ecosystem – the way a homeless person could access services previously:
Funding is equally inefficient
• Insert funding map
Slide from Houston’s, A Way Home
Evolution to a Coordinated System
Programs
Present: Diverse group of independent providers using lots
of methods to achieve various goals
Crisis response system
Vision: A collective network of providers aligning coordinated efforts and resources to maximize impact
Slide/material adapted from Houston’s, A Way Home
Atlanta’s strategic planning work to date
Key Stakeholder Representation• Co-chairs: Protip Biswas, United Way and AJ Robinson, Central
Atlanta Progress• Provider representatives: ACSS, Ga Works, Hope Atlanta,
Nicholas House, PCCI, Mercy Care, Quest, AUM, Salvation Army, First Presbyterian, Caring Works, Ga Law Center, Living Room, Covenant House, Grady Hospital, Gateway 24/7
• Lived experience: current and formerly homeless individuals• Public sector: DBHDD, DCA, AHA, HUD, HHS/ACF• Faith community: St. Luke’s, Church of the Common Ground• Private sector: Regional Commission, Fuqua Foundation• City: APD, Public defender’s office, Mayor’s office, Constituent
Services, Invest Atlanta• Corporate: Parking Company of America, Carter USA
Work To Date• April 2016: Kick off with Mayor Reed
• Committee meetings led by expert consultants:• Leveraging existing resources• Coordinated Entry and system mapping• Systems change using Housing First and funding
innovations• Creating the plan, identifying big goals, objectives
and measures• Chronic, youth, families and Veterans
Big Goals: achieved by new system design and collective impact model
Goal: Rare, brief and nonrecurring Timeline
End Veteran Homelessness by 2017
End Chronic Homelessness by 2019
End Youth Homelessness by 2020
End Family Homelessness by 2020
Leverage, align and strategically allocate resources
Ongoing
Disrupt the system Realign and leverage resources
Performance driven Create right‐sized solutions
Guiding Principles
Guiding Principle 1 - Disrupt the System
• Implementing the Coordinated Entry Program
• Identifying and fill in gaps
• Addressing racial disparities
Move system from an independent-agency approach to an integrated-partner approach by:
Coordinated Entry System Map
Gaps and Shortages
Ending Homelessness
• Housing stock• Emergency
shelter/bridge housing• Housing navigators and
coordinated entry
Stabilization
• Mental health/substance abuse
• Service revenue• Employment• Education• Transportation• Childcare
Guiding Principle 2 - Create Right-size Solutions
• Expand supportive housing and refine integrated service delivery model utilizing Medicaid expansion
• Affordable housing preservation and development aligned/supported with policy
• Rapid rehousing to scale for non-chronic singles and families. Sustain with TANF, ESG, CoC.
• Retool transitional housing for youth, domestic abuse, substance populations
Modify and tailor housing entry and support criteria by population
Effective Housing Interventions by Population
Using Housing First as our foundation…• Emergency shelter – short term bridge housing for all• Transitional housing – long term temporary housing (6-24
months) with intensive services. Ideally suited for domestic violence, youth, and substance abuse
• Rapid rehousing – short or medium term, flexible financial assistance and services to quickly re-house and stabilize individuals and families
• Permanent supportive housing – evidence based housing intervention that combines non-time-limited housing assistance with intensive wrap-around supportive services. Ideal for chronically homeless.
Agency & Provider Changes Required To Get There …
• Shifts for some agencies in the services provided –no longer have to be everything for everybody
• Alignment with best practices and coordinated entry
• Prioritization for key populations
• System wide business rules and accountability for client outcomes
Guiding Principle 3 - Realign and Leverage Resources
• Transparent alignment with city and state entitlement dollars across CoC system
• Fiscal scan and gaps analysis for accountability, needs-based redistribution and unmet needs rank list
• Align funding decisions of private sector grants with Collective Impact Model criteria
Create an unprecedented public-private partnership
Funding is equally inefficient
• Insert funding map
Slide from Houston’s, A Way Home
Current investment
Note: Given ~100 agencies, only ~50% of agencies capturedSource: 2017 Service Provider Survey (N = 47)
ONLY ~30% OF FUNDING IS SPENT ON PERMANENT SOLUTIONS AND…
…ONLY ~15% AND ~5% ARE SPENT ON PERMANENT SUPPORTIVE HOUSING AND RAPID
RE‐HOUSING
Agency funding by type ($M) Agency funding by type ($M)
HUD changes prompt new opportunities to seek and leverage public & private resources
• Homestretch• SAMHSA CABHI Grant $2.4M for 3 years• City and State entitlement funds: ESG, CDBG,
HOPWA• Temporary assistance for needy families (TANF):
shelter and rapid rehousing• Potential Medicaid expansion or waiver • Partnership with State and local agencies, i.e.
DBHDD, DCA, AHA, DHS
Guiding Principle 4 - Create a Performance-driven System
• Use Evidence-based practices for decision making
• Adopt Housing First philosophy across system
• Monitor HMIS practices and data quality
• Establish a system performance baseline and use data to project goals and timelines
Standardize uniform outcomes
Data at a glance: HUD Homeless Count 2011-2016
2,105 2,3151,733 1,375 1,688 1,782
2,340 2,0962,564
1,988 1,592 1,443
1,5421,239
1,4341,037 838
0
1000
2000
3000
4000
5000
6000
7000
2011 2012 2013 2014 2015 2016
UnshelteredTransitionalSheltered
4,063**
5,536
4,797
Source: HUD website;2011 figures disaggregated by Pathways
5,987
Total Homeless
Personsin City of
AtlantaPoint-in-
Time
4,317
**PIT count not conducted this year
Performance Data: a snapshot2016
HUD Performance Measure2016
Atlanta CoC Performance
Percentage of exited participants with increased income at time of exit(all CoC funded projects)
43%
Percentage of participants exiting emergency shelter to homelessness/emergency shelter
85%
Percent of participants exiting transitional shelter to homelessness
52%
Percentage of PSH participants who either remained in PSH or exited to permanent destinations
91%
Executing the Plan…a work in progress
Continuum of Care Governance Council
Planning and Implementation Bodies
SystemStanding Committees:
-HMIS
-Coordinated Entry
-RRH
Chronically
Oversight: TBD
Work Groups: TBD
Veterans
-Shared geography
-List meeting
-Sustainability workgroup
Families
RRH Committee
Youth
Youth Committee
*Slide/material adapted from Houston’s, A Way Home
HOMESTRETCH
Next Steps
• Finalize community stakeholder input
• Draft plan and present to committee
• Present to Governing Council for approval
• Adoption by City Council: xxx, 2017
Opportunities for Alignment
• Use Partners for HOME to:• Consider how your organization can fill necessary gaps not perceived
gaps
• Assess alignment of grant writing/awards with evidence based best practices
• Evaluate grants for compliance for participation in Coordinated Entry
• Request performance outcome data
• HMIS participation
• Support key policy initiatives
Consider using 2017 Strategic Plan as a framework for engagement, decisions and long-range planning initiatives
Conclusion
Who is on the CoC Governing Council and what do they do?
How can I keep informed and involved?
How will we know if and when we “succeeded?”
Who is on the Strategic Plan Committee and when will the SP be available?
Questions? Concerns? Reactions?
Questions, reactions, concerns?
Alignment Framework
Joint Measures/Integrated Strategy
• Partners agree to define and measure success in the same way. Shared strategies reflected in agency plans/goals
Invest Together• Funds are pooled and invested together
Enhance Impact
• Alter services and programs to grow shared impact
Engage• Partners connect and begin to work together
Shannon SaleSenior Vice President, Planning and Business DevelopmentGrady Health System
ARCHI Partner Audit
ARCHI Partner Audit
• 18 breakfasts with growing participation• Approximately 550 individual participants• 70+ organizations have signed an ARCHI
membership agreement• 43% of signed members are health/healthcare
organizations
healthcare28%
advocacy3%
business4%
government13%education
14%
housing2%
payer4%
philanthrophy4%
social services28%
ARCHI Participants, by Sector
health43%
non‐health57%
ARCHI Signed Members (Jan 2017)
supportive services
nutrition
housing
workforce developmenteconomic development
government
advocacy
education
philanthropic
legal aidmental health
Non-health ARCHI Members
Alliant GMCFAmerican Cancer SocietyAtlanta Community Food BankAtlanta Neighborhood Development Partnership (ANDPAtlanta Regional CommissionAtlanta Volunteer Lawyers FoundationCharitable ConnectionsChildKindCHRIS Kids, Inc.Civic League of AtlantaClayton State UniversityClayton State University‐ School of NursingClub E. AtlantaCommunity Foundation for Greater Atlanta, Inc.Community Health interfaith PartnersCommunity of College ParkConcerned Black ClergyDeKalb County Board of HealthDeKalb County GovernmentDiabetes Community Action Coalition, Inc.Emory Fuqua Center for Late Life DepressionEmory HealthcareEmory University ‐ Urban Health Program‐Dept of PedsEmory Urban Health InitiativeEnterprise Community PartnersFriends of Refugees
Fulton County GovernmentFuqua Center/Emory Univ.Georgia Alliance for Health LiteracyGeorgia Dept of Public HealthGeorgia Health Policy CenterGeorgia State UniversityGeorgia Center for NonprofitsGeorgia Institute of TechnologyGet Georgia Reading‐the Annie E. Casey FoundationGlobal DialoguesGrady Health SystemHealth Equity Advocacy & Resource CenterHillsideHistoric Westside Gardens Atl, IncInsure GeorgiaKaiser Permanente of Georgia Legacy Community Housing, GreenSHADESFoundationLive Living International FoundationMarcus Autism Center/Children's Healthcare of Atlanta/Emory Dept of PedsMetro Atlanta Urban FarmMetropolitan CounselingMuni Cares, Inc.Odyssey Family Counseling CenterOne Talent Inc.Open Hand Atlanta
Partnership for Southern EquityPerkins & WillPiedmont HealthcareRiteAid PharmacySaint Joseph's Health SystemSaving Our Sons & Sisters InternationalSouth Fulton Human Services CoalitionSouthside Medical CenterTechBridgeThe Arthur M. Blank Family FoundationThe Carter CenterThe Common Market GeorgiaTruly Living WellUnited Way of Greater AtlantaVeterans Empowerment OrganizationVoices of Georgia's ChildrenWellStarWest End Medical Center Inc.Cathie BergerGordon MeredithPaul StangeGwen SmithErica EdmondEvonne Yancey
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